Please upload a directory of all you clinic locations. Upload as doc, docx, or pdf file

Organization Website*

Contact Information

Contact Name*

PrefixFirstLastSuffix

Contact Title*

Address*

Same as Above

Different than Above

Address*

Street AddressAddress Line 2CityStateZIP Code

Phone

Email*

Please provide contact information of your staff in the following positions

Chief Financial Officer

PrefixFirstLastSuffix

Chief Financial Officer Email

Chief Financial Officer Phone

Medical Officer

PrefixFirstLastSuffix

Medical Officer Email

Medical Director Phone

HIT Manager

PrefixFirstLastSuffix

HIT Manager Email

HIT Manager Phone

Director of Pharmacy

PrefixFirstLastSuffix

Director of Pharmacy Email

Director of Pharmacy Phone

Operations Manager

PrefixFirstLastSuffix

Operations Manager Email

Operations Manager Phone

Financial Information

Federal Tax ID #*

Fiscal Year End (Month)*

Gross Operating Cost*

Required Documents

Articles of Incorporations

Accepted file types: doc, docx, pdf.

Upload as .doc, .docx, or .pdf

Federal Tax Exemption as 501(c)3*

Accepted file types: doc, docx, pdf.

Upload as .doc, .docx, or .pdf

Most recent IRS form 990*

Accepted file types: doc, docx, pdf.

Upload as .doc, .docx, or .pdf

List of your Board of Directors, with officers noted

Accepted file types: doc, docx, pdf.

Upload as .doc, .docx, or .pdf

Bylaws

Accepted file types: doc, docx, pdf.

Upload as .doc, .docx, or .pdf

Most recent financial audit

Accepted file types: doc, docx, pdf, xls, xlsx.

Upload as .doc, .docx, .xls, .xlsx, or .pdf

Electronic Logo*

Marketing Material (Optional)

Drop files here or

Affiliate Agreement

This signature certifies that the party/parties above and whose signature appears below is the official delegate to the Community Clinic Association of Los Angeles County (CCALAC). If an organization, the delegates have their primary employment at the organization listed on this application. By signing you agree that you have no conflict of interest with other CCALAC member or affiliate agencies. If there is a change in your delegates, a written notification will be sent to CCALAC. This also represents your organization’s agreement to the activities of the CCALAC. It is understood that all information provided will be treated confidentially.*